—  SPECIALTY CONFERENCE HANDOUT  — Gastrointestinal Pathology Tuesday, March 23, 7:30 PM Salon 3 and Balconies Clinical histories are printed below. Click on the case numbers for text and references of each case. Click on each slide thumbnail image for an enlarged view Moderator: LAURA LAMPS University of Arkansas for Medical Sciences, Little Rock, AR Disclosure: In accordance with ACCME guidelines regarding disclosure, the USCAP policy requires that faculty members who have a significant financial or other relationship with a commercial company, entity, or service (which will be discussed in this Symposium) must disclose this to attendees. The Academy also requires that speakers disclose any products that are not labeled for the use under discussion. The speakers listed below have indicated they have nothing to disclose. Panelists: DHANPAT JAIN, Yale University School of Medicine, New Haven, CT SCOTT OWENS, University of Pittsburgh School of Medicine, Pittsburgh, PA WENDY L. FRANKEL, The Ohio State University School of Medicine, Columbus, OH DAVID A. OWEN, University of British Columbia, Vancouver, British Columbia, Canada WADE S. SAMOWITZ, University of Utah Medical Center, Salt Lake City, UT Clinical Histories and Still Images are displayed below. Click on slide thumbnail images for an enlarged view. If you have any difficulties viewing these slides, email or call George Clay at +1.724.449.1137. Case 1 - Click here for Text and References Submitted by: Dhanpat Jain - Yale University School of Medicine, New Haven, CT Clinical Summary: Patient is a 47 year old asymptomatic Portuguese lady who presented to the gastroenterologist for screening endoscopy for strong family history of stomach cancer. Endoscopy revealed a 1cm ulcer in the gastric cardia that appeared benign, however, biopsies were performed and she subsequently underwent gastric resection. Grossly the ulcer was shallow without any thickening of the mucosal folds around it or thickening of the wall. Representative photomicrographs of the lesion are given. Case 1 - Figure 1 Section from the edge of the gastric ulcer showing infiltration by signet-ring cells at low magnification. Case 1 - Figure 2 Higher magnification showing the signet-ring cells. Case 1 - Figure 3 Higher magnification showing the signet-ring cells showing the typical morphology with single large mucin vacuole and eccentrically placed nucleus . Case 1 - Figure 4 Section from the deeper part of the gastric wall showing infiltration by tumor cells lacking a mucin vacuole and having a histiocyte-like appearance. Case 1 - Figure 5 Immunostain for keratin AE1/AE3 showing strong positivity in the histiocyte-like tumor cells. Case 1 - Figure 6 Section from the non-neoplastic gastric mucosa showing mild chronic gastritis and intestinal metaplasia. Case 2 - Click here for Text and References Submitted by: Scott Owens - University of Pittsburgh School of Medicine, Pittsburgh, PA Clinical Summary: A 50 year-old man presented three days after an umbilical hernia repair with rapidly-progressive left axillary and lower anterior chest pain, accompanied by jaundice and dark urine.  His amylase and bilirubin were elevated and he was presumptively diagnosed with biliary pancreatitis.  A subsequent CT scan showed a large (8.8 cm) enhancing mass in the second portion of the duodenum, which an endoscopic ultrasound found to be a submucosal/intramural mass with cystic areas, located adjacent to the papilla of Vater.  Clinically, it was felt most likely to be a gastrointestinal stromal tumor.  The mass was locally excised approximately two months after the patient's initial presentation. Case 2 - Figure 1 Gross photograph of submucosal tumor with variegated surface and areas of hemorrhage. Case 2 - Figure 2 Low-power photomicrograph of tumor showing submucosal location and variable histology; areas of spindle cells are admixed with cells arranged in nests and cords. Case 2 - Figure 3 Medium-power view of epithelioid cells arranged in nests and cords, with overlying reactive duodenal mucosa. Case 2 - Figure 4 High-power view of nests of epithelioid cells. Case 2 - Figure 5 High-power view of intimately admixed spindle cells and large cells with round, vesicular nuclei and prominent nucleoli. Case 2 - Figure 6 High-power photomicrograph illustrating the three cells types comprising the tumor: spindle cells (upper right corner), epithelioid cells in nests and cords, and large cells with round nuclei and prominent nucleoli. Case 2 - Figure 7 High-power view of largest tumor cells, which have abundant cytoplasm, eccentric nuclei with prominent nucleoli, and basophilic substance at their periphery. Case 2 - Figure 8 Synaptophysin immunostain is positive in most of the tumor cells (bottom 1/3 of photomicrograph). Case 2 - Figure 9 CAM5.2 immunostain is positive in the epithelioid cell component. It also highlights the epithelium in the overlying mucosa. Case 3 - Click here for Text and References Submitted by: Wendy L. Frankel - The Ohio State University School of Medicine, Columbus, OH Clinical History: 58 year old man with no personal history of malignancy or other significant medical history was noted to have two tumors at colonoscopy. The tumors were located in his transverse colon and rectosigmoid. Case 3 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 3 - Figure 1 Low power view of the tumor with a pushing border and adjacent lymphoid aggregates. Case 3 - Figure 2 In some areas, the cells form glands and nests. Case 3 - Figure 3 In other areas, the tumor cells show a medullary pattern. The malignant cells are arranged in a somewhat trabecular pattern and contain vesicular chromatin with nucleoli. There is a lymphoid infiltrate surrounding tumor cells. Case 3 - Figure 4 High power view of an area with undifferentiated sheets of tumor cells. Case 3 - Figure 5 The tumor is immunoreactive with MLH1 and PMS2. Case 3 - Figure 6 MSH2 and MSH6 mark lymphocytes and benign epithelial cells but staining is absent in tumor cells. Case 3 - Figure 7 The algorithm used at the Ohio State University on all colorectal carcinoma (CRC) patients to identify Lynch Syndrome and microsatellite instability (from Bellizzi and Frankel, Adv Anat Pathol, 2009). Case 4 - Click here for Text and References Submitted by: David A. Owen - University of British Columbia, Vancouver, British Columbia, Canada Clinical Summary: The patient is a man aged 62 who presented with a one year history of intermittant dysphagia with occasional episodes of choking. An upper GI endoscopic examination was planned but before the endoscope was fully inserted the patient "burped" and then inhaled deeply. The endoscopist observed that a "large" polyp had refluxed from the upper esophagus and entered the trachea. The patient's airway was partly obstructed and he became cyanosed. Emergency help was summoned and with difficulty the polyp was removed from the airway and returned to the esophagus. A CT scan of the neck was performed which showed a lobulated fatty lesion present in the hypopharynx. This measured 61 X 46 X 19 mm. No lymphadenopathy was identified. It was possible to remove the polyp using an operating laryngoscope. The base of the polyp was in the upper esophagus. The tip was located 12cm distally in the mid- esophagus. It was excised in two pieces. The laboratory received two polypoid masses each of which measured 45 X 40 X 40mm. They were described as consisting of "fluctuant fatty material". The surface mucosa was smooth and intact with no obvious ulceration. Pertinent Laboratory Data: This patient was known to be a type 1 diabetic with elevated blood glucose levels. All other laboratory tests were normal. Case 4 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 4 - Figure 1 Origninal slides showing the gross, low power views and high power views of the esophageal polyp C Case 4 - Figure 2 Origninal slides showing the gross, low power views and high power views of the esophageal polyp C Case 4 - Figure 3 Origninal slides showing the gross, low power views and high power views of the esophageal polyp C Case 4 - Figure 4 Origninal slides showing the gross, low power views and high power views of the esophageal polyp C Case 4 - Figure 5 Origninal slides showing the gross, low power views and high power views of the esophageal polyp C Case 4 - Figure 6 Origninal slides showing the gross, low power views and high power views of the esophageal polyp C Case 4 - Figure 7 Origninal slides showing the gross, low power views and high power views of the esophageal polyp C Case 4 - Figure 8 Additional images of polyp Case 4 - Figure 9 Additional images of polyp Case 4 - Figure 10 Additional images of polyp Case 4 - Figure 11 Lipoblasts and cells from a well- differentiated liposarcoma, for comparative purposes Case 4 - Figure 12 Lipoblasts and cells from a well- differentiated liposarcoma, for comparative purposes Case 4 - Figure 13 Lipoblasts and cells from a well- differentiated liposarcoma, for comparative purposes Case 5 - Click here for Text and References Submitted by: Wade S. Samowitz - University of Utah Medical Center, Salt Lake City, UT Clinical Summary: A 57 year old insulin-dependent diabetic man presented at an outside institution with lower abdominal pain, anorexia, fatigue, low grade fevers and constipation. The WBC count was 16,400/µl with 8% eosinophils. CT showed an 18 cm mass involving the transverse colon and stomach. Left colon biopsy showed “active colitis with epithelioid granulomas.” The presumptive diagnosis was Crohn's disease and treatment with mesalamine was begun. Subsequent enlargement of the mass prompted surgical resection of a segment of colon and part of the greater curvature of the stomach. Histologic interpretation was “diverticular disease with perforation and foreign body reaction.” The patient was discharged but was then admitted to our institution because of an enlarging mass now involving the pancreatic tail and left kidney. Slides from the initial operation were reviewed at our institution. Case 5 - Figure 1 Submucosa granuloma with hyphal form with Splendore-Hoeppli phenomenon. Case 5 - Figure 2 Large area of necrosis in muscularis propria and submucosa ringed by giant cells. Case 5 - Figure 3 Giant cells and pallisading histiocytes at the edge of the area of necrosis. Case 5 - Figure 4 Hyphae (both longitudinal and in cross-section) with Splendore-Hoeppli phenomenon. Case 5 - Figure 5 Hyphae with Splendore-Hoeppli phenomenon. Case 5 - Figure 6 Prominent eosinophil infiltrates. Case 5 - Figure 7 Cross-section of hyphal element with Splendore-Hoeppli phenomenon at bottom of photomicrograph; numerous Charcot-Leyden crystals above the fungus. Case 5 - Figure 8 Numerous hyphae with Splendore-Hoeppli phenomenon. Handouts for all Specialty Conferences will be accessible via the "Educational Materials" section on the homepage the morning after each respective conference. Printed copies of the handout will not be available at the meeting.